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ADHD and Tourette's Treatment

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ADHD and Tourette Syndrome: A Treatment Challenge

Colin Bridgeman

Pennsylvania State University

Penn State College of Medicine

2004

Tourette’s Syndrome or Disorder (TS):

1) First described by Georges Gilles de la Tourette in 1885

2) Epidemiology:

A) The occurrence of Tourette Syndrome in school-age populations has been reported to be anywhere from 0.7% to 4.2% depending on the diagnostic criteria used.

B) The mean age of onset is 6.7 years. (Robertson 2003)

3) Diagnosis criteria from Tourette Syndrome Classification Study Group:

A) multiple motor tics and one or more phonic tics must be present at some time during the illness

B) tics must occur many times a day, almost every day or intermittently throughout a period of more than a year

C) the anatomical location of the tics, type, complexity, or severity of the tics must change over time

D) onset must be before age 21

E) must not be explainable by other medical condition

F) tics must be witnessed by reliable examiner

Attention Deficit Hyperactivity Disorder (ADHD):

1) Epidemiology:

A) The prevalence of ADHD is estimated to be between 8-10% in school-aged children.

B) Four times more common in boys than girls

C) Three subtypes of ADHD exist including: Inattentive, Hyperactive-Impulsive, and Combined

2) Diagnosis Criteria for ADHD from DSM IV include, but not limited to:

A) Symptoms of inattention and/or hyperactivity and impulsivity, such as fidgeting, failure to pay attention to details, difficulty organizing tasks, easily distracted, and interruptive.

B) Symptoms present for at least six months

C) Symptoms present in more than one setting

D) Symptoms present before age seven

E) Symptoms impair academic, social, or occupational activities

F) Symptoms inconsistent for developmental level

Co-morbidity of Tourette syndrome and ADHD:

1) Tics and TS occur in as many as 50% of the children diagnosed with ADHD (Nass, 2002).

2) ADHD is even more common in TS, with co-morbidity reported as high as 90% (Nass, 2002)

There is debate in the community about whether TS and ADHD, along with OCD, are separate discrete disorders or whether they are differing manifestations of a common spectrum of disorders with a common cause. (Olson, 2004)

In regards to the heritable factors responsible for ADHD and TS, Comings reported on the genetic relationship of ADHD and TS

ź Inheritance is polygenic for both disorders

ź Multiple genes are responsible and are additive in their effects

ź Both disorders are caused by shared genes

ź Caused by genes that regulate the dopamine/serotonin/GABA balances in the brain

Regardless of the classification of TS and ADHD as distinct or related disorders it is clear that the need to manage one in the context of the other is necessary.

Standard Pharmacological Treatment choices for ADHD:

Stimulants:

ź Methylphenidate

ź Dextroamphetamine

ź Pemoline (limited use due to liver toxicity)

Non-stimulant medications:

ź Atomoxetine

ź Clonidine

ź Guanfacine

Anti-depressants:

ź TCAs (e.g. imipramine, desipramine, nortriptyline)

ź DA reuptake inhibitors (e.g. buproprion)

Stimulant medications are generally considered to be the most effective pharmacological treatment choice for ADHD.

Stimulant use for ADHD inpatients with co-morbid Tourette syndrome is controversial because of concern about the exacerbation of tic symptoms by the stimulant medications.

Many studies have looked the pharmacological treatment choices for patients with ADHD and Tourette syndrome.

Kurlan et al (2002) - Treatment of ADHD in children with tics

Goal of Study:

ź Determine the efficacy of methylphenidate (most commonly prescribed drug for ADHD), and clonidine (most commonly prescribed alternative) in patients with ADHD and tic disorders

Design:

ź Multicenter, double-blind trial

ź 136 children diagnosed with ADHD and a tic disorder were randomly assigned to four different pools

1) methylphenidate alone

2) clonidine alone

3) methylphenidate and clonidine

4) placebo

ź 16 week long trial

Results and Conclusions:

ź Methylphenidate, clonidine, and clonidine + methylphenidate all showed improvement in ADHD symptom measures

ź Clonidine + methylphenidate showed the greatest benefit

ź Methylphenidate did not worsen tics as compared to placebo

ź Tic severity was decreased in all groups, with clonidine + methylphenidate being the most effective followed by clonidine alone and then methylphenidate alone

Spencer et al (2002) - A double-blind comparison of desipramine and placebo in children and adolescents with chronic tic disorder and co morbid ADHD

Goals:

ź Determine the efficacy of desipramine in children with ADHD and tic disorders (e.g. Tourette syndrome)

Design:

ź Double blind trial

ź 41 children ages 5-17 with diagnosis of ADHD and tic disorder

ź Two study groups: 1. Desipramine (3.5 mg/kg/day), 2. Placebo

ź Measurement of ADHD core symptoms and tic symptoms

Results and Conclusions:

ź Despiramine significantly reduced ADHD symptoms compared to placebo

ź Tic symptoms were also significantly reduced with desipramine compared to placebo

References

1. Castellanos, Xavier F. Stimulants and tic disorders. Arch Gen Psychiatry. 1999;56:337-338.

2. Comings, David. Clinical and molecular genetics of ADHD and Tourette’s syndrome: Two related polygenic disorders. Annals New York Academy of Sciences. 2001; 931:50-83.

3. Jankovic, Joseph. Tourette’s syndrome. The New England Journal of Medicine. 2001; 345: 1184-1192.

4. Krull, K. Evaluation and diagnosis of attention deficit disorder in children. UpToDate 2004.

5. Krull, K. Treatment and prognosis of attention deficit hyperactivity disorder in children. UpToDate 2004

6. Kurlan R, et al. Treatment of ADHD in children with tics. Neurology. 2002; 58:527-535.

7. Nass R, Bressman S. Attention deficit hyperactivity disorder and Tourette syndrome. Neurology 2002; 58: 513-514.

8. Olson S. Making sense of Tourette’s. Science. 2004; 305:1390-1392.

9. Robertson, Mary. Diagnosing Tourette syndrome: Is it a common disorder. Journal of Psychosomatic Research. 2003; 55:3-6.

10. Spencer T, Biederman J, Coffey B, Geller D, Crawford M, Bearman S, Tarazi R, Faraone S. A double blind comparison of Desipramine and placebo in children and adolescents with chronic tic disorder and co morbid Attention Deficit/Hyperactivity disorder. Arch Gen Psychiatry. 2002; 59:649-656.

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